Anxiety in allergy and atopic dermatitis

Psychopathological symptoms in dermatology: A basic approach toward psychocutaneous disorders

Dermatological conditions impact not only an individual's physical body but also their psychological health. Similar to how cutaneous conditions can affect one's psychological health, worsening psychological conditions can exacerbate or even induce dermatological conditions. There are four common psychiatric pathologies typically found in dermatology practices: depressive symptoms, anxiety symptoms, obsessive-compulsive disorder behaviors, and psychosis. Common cutaneous disorders associated with these psychopathological symptoms include, but are not limited to, psoriasis, acne vulgaris, atopic dermatitis, urticaria, trichotillomania, excoriation disorder, and delusions of parasitosis. The goal of this review is to examine the relationship between these four psychopathological symptoms with common psychodermatological conditions and to help providers better diagnose and implement appropriate psychological support to treat their patients.

Increasing patient-reported allergies are not associated with pain, functional outcomes, or satisfaction following medial patellofemoral ligament reconstruction: a retrospective comparative cohort study

Background

Patient-reported allergies (PRAs) are often stigmatized as a potential nonmodifiable risk factor for increased pain and worse functional outcomes following surgery. However, there is a dearth of literature directly assessing the impact of PRAs on outcomes in sport surgeries such as medial patellofemoral ligament reconstruction (MPFLR). The purpose of our study was to determine whether PRAs were associated with worse outcomes following MPFLR.

Methods

We conducted a retrospective review of patients who underwent MPFLR at our institution from 2011 to 2019. Patients were included if they had at least 12 months of follow-up. PRAs were obtained from preoperative medical assessments and categorized by drug class. Demographic and perioperative data were obtained from electronic medical records. Postoperative outcomes were measured using a telephone survey and included recurrent instability, Visual analog scale (VAS) for pain, VAS for sports, Kujala score, MPFL-Return to Sport after Injury (MPFL-RSI) score, and overall satisfaction score. Multiple linear regression was used to determine association between PRAs and outcome measures, and p-values less than 0.05 were considered significant.

Results

The cohort included 141 MPFLR. Most patients were female (98, 70%) with an average age of 25 years (range 12–56 years). Average follow-up time was 47 months. Forty-seven patients (33%) reported at least one PRA. There were no significant differences in postoperative pain, functional outcomes, satisfaction, or return to sport between patients with or without PRAs (all p > 0.05). Absence of antibiotic PRAs was predictive of higher VAS (p < 0.007), but there were no other differences. There were no significant differences in outcomes between patients without PRAs, PRAs without a concomitant psychiatric disorder, or PRAs with a concomitant psychiatric disorder (all p > 0.05).

Conclusions

In conclusion, PRAs with or without concomitant psychiatric diagnoses are not associated with worse postoperative pain, functional outcomes, or satisfaction following MPFLR with allograft, dispelling common misconceptions that increased number of allergies or psychiatric diagnoses lead to inferior surgical outcomes. Presence of antibiotic allergies was associated with lower VAS postoperative pain score. Future research should investigate the relationship between PRAs and other surgeries in the field of sports medicine.

Probing the Skin–Brain Axis: New Vistas Using Mouse Models

Inflammatory diseases of the skin, including atopic dermatitis and psoriasis, have gained increasing attention with rising incidences in developed countries over the past decades. While bodily properties, such as immunological responses of the skin, have been described in some detail, interactions with the brain via different routes are less well studied. The suggested routes of the skin–brain axis comprise the immune system, HPA axis, and the peripheral and central nervous system, including microglia responses and structural changes. They provide starting points to investigate the molecular mechanisms of neuropsychiatric comorbidities in AD and psoriasis. To this end, mouse models exist for AD and psoriasis that could be tested for relevant behavioral entities. In this review, we provide an overview of the current mouse models and assays. By combining an extensive behavioral characterization and state-of-the-art genetic interventions with the investigation of underlying molecular pathways, insights into the mechanisms of the skin–brain axis in inflammatory cutaneous diseases are examined, which will spark further research in humans and drive the development of novel therapeutic strategies.

Psychological profiles of patients with suspected drug allergy

Background

Several studies demonstrate an important association between allergic diseases and patients' psychological characteristics.

Objective

To evaluate any differences in the psychological characteristics of patients studied for suspected drug allergy in comparison with healthy controls. A secondary aim was to assess differences between patients with confirmed versus excluded drug allergy, with respect to the clinical aspects.

Methods

The psychological characteristics of 115 consecutive patients >16 years-old, studied for suspected drug allergy were assessed. They were compared with healthy controls. Four validated questionnaires were used to evaluate anxiety, depression, alexithymia, and personality type.

Results

Eighty-eight patients completed the evaluation: 34 had confirmed drug allergy and 33 excluded. Forty-eight healthy subjects filled the 4 questionnaires. Increased neuroticism was associated with increased odds of belonging to the excluded drug allergy group (odds ratio [OR], 1.374; 95% confidence interval [CI], 1.173–1.609). Increased neuroticism (OR, 1.244; 95% CI, 1.065–1.453) and increased anxiety (OR, 1.210; 95% CI, 1.084–1.351) were associated with increased odds of confirmed drug allergy. However, higher extraversion decreased this likelihood (OR, 0.755; 95% CI, 0.643–0.888). The odds of having confirmed drug allergy was reduced by 79.7% (OR, 0.203; 95% CI, 0.060–0.694) for patients with 2 suspected drugs and by 84.6% (OR, 0.154; 95% CI, 0.029–0.809) for those with ≥3 in comparison to those with only one. Patients with moderate to severe reactions were more likely to have confirmed drug allergy (OR, 4.295; 95% CI, 1.105–16.693) than those with milder manifestations.

Conclusion

Our results highlight that patients with drug allergy have a distinctive psychological profile. Psychological assessment may help to identify patients that would benefit from a targeted intervention.

Social and psychosocial effects on atopic eczema symptom severity - a scoping review of observational studies published from 1989 to 2019

Social and psychosocial factors are thought to have an effect on the course of atopic eczema. The aim of this scoping review was to search for and summarize observational studies that investigated the effects of (psycho-)social factors on symptoms in atopic eczema and to identify research gaps. We searched PubMed and PsycINFO for literature published between 1 January 1989 and 31 December 2019 using a systematic search strategy. We included observational studies that analysed the effect of (psycho-)social factors on symptom severity in atopic eczema patients. Reviews and non-observational studies, articles with research on animals, and articles with languages other than English or German were excluded. We identified 17 observational studies that met the inclusion criteria. Several studies found significant results for an exacerbating effect of stress on atopic eczema severity. Although coping and social support does not seem to moderate the effect of stress, coping strategies might mediate the impact that stress has on symptoms. Depression is associated with atopic eczema severity. The effect of depression as a consequence of atopic eczema severity is stronger than the effect as an exacerbating factor. Illness identity, anger, frustration and psychosomatic states have been found to affect atopic eczema symptoms. For attachment security, anxiety and social status, contradictory results were found. Statistically non-significant results were reported for personality, being in a partnership, satisfaction with the partnership, childhood experiences and body consciousness. Only the association between psychosocial stress and atopic eczema symptom severity seems robust. To date, other (psycho-)social factors, especially protective and health-promoting factors, were analysed only in a few studies, mostly with low sample sizes and cross-sectional design. Biopsychosocial interactions between stress, protective factors and the course of atopic eczema as well as the psycho-neuroimmunological mechanisms underlying those interactions are considered fields for future research contributions.

Biological Sex and IgE Sensitization Influence Severity of Depression and Cortisol Levels in Atopic Dermatitis

BACKGROUND

Depression is a common comorbid condition with atopic dermatitis (AD), particularly during the active disease cycle. Controversial results regarding the contribution of biological sex, immunoglobulin E (IgE) sensitization, and cortisol on AD severity and comorbid depression justify further investigation.

OBJECTIVE AND METHODS

To explore the influence of sex and IgE sensitization on biochemical and psychological parameters, and severity of AD, a case-control study of 105 volunteers (56 AD, 49 healthy controls (HC); 50 males, 55 females) was conducted over 10 weeks, starting at dermatological symptom onset. Disease severity, serum IgE, cortisol and testosterone levels, and depression scores were assessed at study baseline and after 10 weeks of conventional treatment.

RESULTS

Dermatological severity differed among AD males by IgE sensitization and was elevated in males with extrinsic atopic dermatitis (EAD). Hamilton Depression Rating Scale (HAMD) scores were elevated in all patients at study baseline and improved with symptom reduction to HC levels, except female EAD. Severity of depression and dermatitis were correlated in EAD males at baseline and at week 10. Serum cortisol was elevated in male EAD at baseline, in contrast to males with intrinsic atopic dermatitis (IAD) at week 10. In addition, cortisol levels were found negatively correlated with SCORAD and HAMD scores in EAD males at week 10.

CONCLUSION

Pathophysiological features of AD and depression are likely related to different inflammation-based effects and appear to be biological sex-dependent. Cortisol levels depend on biological sex and IgE sensitization in AD and increase in males with EAD at exacerbation and IAD males at resolution. Biological sex-related disease triggers, IgE sensitization, and cortisol levels are important for the understanding of the mechanisms underlying AD and comorbid depression.

Determination of depression, anxiety and stress (DAS) levels in patients with atopic dermatitis: a case-control study

The present study was aimed at comparing depression, anxiety and stress (DAS) levels of individuals with atopic dermatitis with those of the individuals without atopic dermatitis, and to examine the DAS levels of the patients with atopic dermatitis in terms of their socio-demographic characteristics. Case control study conducted in a city in western Turkey. The present study in which the relational screening model was used was conducted with patients with atopic dermatitis who presented to the Dermatology Clinic/Polyclinic of a university hospital and healthy subjects, and volunteered to participate in the study. The study conducted between December 2017 and February 2018 included 150 people (75 healthy subjects, 75 patients with atopic dermatitis). To collect the study data, the participants were administered the Socio-demographic Characteristics Questionnaire prepared by the researcher and the Depression, Stress and Anxiety Scale (DASS-42). No significant difference was determined between the mean DASS scores obtained by the atopic dermatitis patients and those obtained by the healthy subjects in the control group (p > 0.05). Of the atopic dermatitis patients, 58.7%, 82.3% and 49.3% were within the normal ranges in terms of the mean scores they obtained from the stress, depression and anxiety subscales respectively. In the present study, the mean scores obtained from the depression and anxiety subscales by working atopic dermatitis patients were higher than those obtained by the nonworking patients (p < 0.05). The mean scores obtained from the stress subscale by the smokers with atopic dermatitis were higher than those obtained by the non-smokers with atopic dermatitis.

Patients with atopy exhibit reduced cortisol awakening response but not cortisol concentrations during the rest of the day

It has been documented that cortisol release in response to acute stressors is reduced in patients with atopic dermatitis, allergic rhinitis, and other atopic diseases compared to that in healthy subjects. We aimed to test the hypothesis that atopic patients exert reduced salivary cortisol awakening response (CAR) in comparison with healthy subjects. The hypothesis was tested on a stressful and a relax day selected subjectively. Moreover, we evaluated the impact of trait anxiety. The sample consisted of 60 subjects, out of which 28 were patients with atopy and 32 healthy volunteers of both sexes. Saliva samples were collected in the morning to evaluate CAR as well as in the early afternoon and evening to look at cortisol concentrations during the rest of the day. The results showed reduced CAR in atopic patients compared to that in healthy subjects. This effect was modulated by sex with a significant difference observed in males. While CAR was reduced, atopic patients had unchanged cortisol concentrations throughout the day. The evening cortisol was even higher in atopic patients. If the subjects were stratified according to the trait anxiety, no significant differences in CAR between high and low anxiety were observed. No differences in cortisol variables including CAR were observed between the stressful and relax day. In conclusion, this study presents evidence on reduced CAR suggesting an insufficient HPA axis reactivity in atopy. Furthermore, the data in atopic patients demonstrate that reduced HPA axis reactivity does not necessarily mean lower cortisol concentrations throughout the day. This might be of relevance to immune system function and the course of the disease.

Keloid risk in patients with atopic dermatitis: a nationwide retrospective cohort study in Taiwan

OBJECTIVE

The pathogenesis of keloid is largely unknown. Because keloid and atopic dermatitis have overlapping pathophysiological mechanisms, we aimed to evaluate keloid risk in patients with atopic dermatitis.

STUDY DESIGN

Population-based retrospective cohort study.

SETTING

The Taiwan National Health Insurance Research Database was used to analyse data for people who had been diagnosed with atopic dermatitis.

PARTICIPANTS

We identified 8371 patients with newly diagnosed atopic dermatitis during 1996-2010. An additional 33 484 controls without atopic dermatitis were randomly identified and frequency matched at a one-to-four ratio.

PRIMARY AND SECONDARY OUTCOME MEASURE

The association between atopic dermatitis and keloid risk was estimated using Cox proportional hazard regression models.

RESULTS

After adjustment for covariates, the atopic dermatitis patients have a 3.19-fold greater risk of developing keloid compared with the non-atopic dermatitis group (3.19vs1.07 per 1000 person-years, respectively). During the study period, 163 patients with atopic dermatitis and 532 patients without atopic dermatitis developed keloid. Notably, keloid risk increased with severity of atopic dermatitis, particularly in patients with moderate to severe atopic dermatitis.

CONCLUSIONS

Our results indicate that patients with atopic dermatitis had a higher than normal risk of developing keloid and suggest that atopic dermatitis may be an independent risk factor for keloid.

Psychosomatic factors of atopic dermatitis exacerbation

BACKGROUND

The aim of this study was to estimate whether the stress, lack of social support, and poor emotional relationships influence the recurrence of AD in adults.

METHODS

Case-control study comprised 66 outpatients with AD and 132 controls with different skin diseases believed to be slightly influenced by psychosomatic factors. Participants were treated at the Department of Dermatology - Military Medical Academy and City Department for Skin and Venereal Diseases from January to June 2014. Stressful life events were assessed using the Paykel's Interview for Recent Life Events. The attachment relationship and perceived social support were assessed with the Experiences in Close Relationships Scale and with the Multidimensional Scale of Perceived Social Support, respectively. Univariate and multivariate logistic regression analyses were applied.

RESULTS

AD patients had significantly higher anxiety scores when initiating a close emotional relationship and when avoiding an affective attachment (OR = 1.49; CI = 1.13-1.97; P = 0.005 and OR = 1.63; CI = 1.16-2.30; P = 0.005, respectively). Perceived social support from family and friends was significantly lower among cases compared to controls (OR = 0.93; CI = 0.88-0.98; P = 0.009 and UO = 0.94; CI = 0.89-0.99; P = 0.027, respectively).

CONCLUSIONS

AD patients had higher anxiety scores, and those with low social support tended to have more frequent disease recurrence. The number of stressful life events did not differ between studied groups.

Economic Impact of Atopic Dermatitis in Adults: A Population-Based Study (IDEA Study)

OBJECTIVE

To determine resource usage and costs associated with atopic dermatitis in adults according to severity and comorbid conditions in daily clinical practice.

PATIENTS AND METHODS

We performed an observational, retrospective study based on a review of registries of patients aged ≥18 years who sought health care in 2013 and 2014 in an area of Catalonia, Spain, with a population of 215,634 persons. We established 3 classes of severity depending on the treatment prescribed. The variables evaluated were total comorbid conditions, concomitant/specific medication, and direct/indirect health care costs. The statistical analysis was based on multiple regression models. Statistical significance was set at P<.05.

RESULTS

We included 6,186 patients with a diagnosis of atopic dermatitis (mean age, 47.1 years; women, 61.6%). We established 3 groups based on severity, as follows: mild (n=3,445 [55.7%]); moderate (n=2,361 [38.2%]); and severe (n=380 [6.1%]). Severe atopic dermatitis was associated with risk of presenting comorbid conditions (β=0.192), namely, asthma (β=0.138), depression (β=0.099), cardiovascular events (β=0.087), obesity (β=0.085), and smoking (β=0.025); P<.001. Costs reached €9.3 million (health care costs, 75.5%; loss of productivity, 24.5%), with an average unit cost of €1,504 per year. The corrected average unit cost (ANCOVA) was greater in severe atopic dermatitis compared with moderate and mild disease (€3,397 vs. €2,111 vs. €885; P<.001), respectively.

CONCLUSIONS

Severe atopic dermatitis generates considerable usage of health care resources and high costs for the National Health System. These are in proportion with the severity of the disease. General comorbid conditions and asthma were the factors with the greatest impact on health care costs.

Association between Stress and the HPA Axis in the Atopic Dermatitis

The hypothalamic–pituitary–adrenal (HPA) axis is one of the body’s neuroendocrine networks that responds to psychological stress (PS). In the skin, there exists a peripheral HPA axis similar to the central axis. Glucocorticoids (GCs) are key effector molecules of the HPA axis and are essential for cutaneous homeostasis. Atopic dermatitis (AD) is a condition typically characterized by a chronic relapsing course that often results in PS. HPA dysfunction is present in AD patients by the decreased response of GCs elevation to stress as compared to those unaffected by AD. Nevertheless, in skin, acute PS activates several metabolic responses that are of immediate benefit to the host. During the acute phase of PS, increased endogenous GCs have been shown to provide benefit rather than by aggravating cutaneous inflammatory dermatoses. However, a chronic T helper cell type 2 (Th2) predominant cytokine profile acts as a negative feedback loop to blunt the HPA axis response in AD. In this article, we reviewed the role of CRF, pro-opiomelanocortin (POMC)-derived peptides, GCs of the HPA, and 11β-hydroxysteroid dehydrogenase 1 (11β-HSD1) in AD, with a discussion of the pathogenetic mechanisms of inflammation and skin barrier functions, including antimicrobial defense, and their association with PS.

Enhanced Expression of Genes Related to Xenobiotic Metabolism in the Skin of Patients with Atopic Dermatitis but Not with Ichthyosis Vulgaris

Previous transcriptome analyses underscored the importance of immunological and skin barrier abnormalities in atopic dermatitis (AD). We sought to identify pathogenic pathways involved in AD by comparing the transcriptomes of AD patients stratified for filaggrin (FLG)-null mutations to those of both healthy donors and patients with ichthyosis vulgaris. We applied RNA sequencing to analyze the whole transcriptome of nonlesional skin. We found that 607 genes (476 up-regulated and 131 down-regulated by >2-fold) and 193 genes (172 up-regulated and 21 down-regulated by >2-fold) were differentially expressed when all AD or ichthyosis vulgaris patients were compared with healthy donors, respectively. Expression of genes involved in RNA/protein turnover and adenosine triphosphate synthesis, as well as genes involved in cell death, response to oxidative stress, DNA damage/repair, and autophagy, were significantly enriched in AD skin and, to a lesser extent, in ichthyosis vulgaris skin. FLG-null mutations appear to hardly interfere with current observations. Genes related to xenobiotic metabolism were up-regulated in AD skin only, as were genes related to arachidonic, linoleic, and α-linolenic acid metabolism. Thus, this work newly links AD pathogenesis to aberrant expression of genes related to xenobiotic metabolism.

[Dermatological diseases and their importance for psychiatry]

The relationship between skin and psychiatric disorders is not an uncommon occurrence in the clinical practice; however, there are only a few systematic studies and in addition knowledge about the neurobiological and immunological mechanisms is lacking. Impairments and disorders of the skin are often an (early) sign of a psychiatric disorder. In the sense of true psychosomatics, psychiatrists should also be aware of this relationship as far as possible. This review article focuses on the most important dermatological diagnoses in relation to the respective psychiatric comorbidities and presents the most important aspects of epidemiology, symptomatology, pathophysiology and treatment options.

Psychiatry outpatient visits by atopic dermatitis patients varying in the complexity of their prescriptions: A nationwide cohort study conducted from 2005 to 2013

The uncomfortable symptoms of atopic dermatitis (AD) often trigger psychological stress.We investigated the association between AD severity and outpatient visits to psychiatrists using Korean National Health Insurance claims data from 2004 to 2013.This was a retrospective cohort analysis; we estimated hazard ratios (HRs).Of the 266,182 subjects, 18,290 (6.9%) had a history of visiting a psychiatrist, and 25,419 (9.5%) were diagnosed with AD. Compared with the subjects without AD, subjects with AD had a higher HR for visiting a psychiatrist (3.70, 95% confidence interval [CI]:48 3.43-3.98), and this significantly increased as the complexity of the AD medications increased. Subjects who received topical treatments plus a systematic steroid (HR: 4.88, 95% CI: 4.51-5.27) and those who received topical treatments plus a systematic steroid plus a systematic calcineurin inhibitor (HR: 9.56, 95% CI: 4.29-21.28) had higher HRs compared with those without AD.Severe AD patients exhibited greater psychological stress than those without AD or with mild AD symptoms. Moreover, medication diversity may represent an efficient and low-cost method by which to identify a vulnerable population.

Association of Perceived Stress with Atopic Dermatitis in Adults: A Population-Based Study in Korea

Atopic dermatitis (AD) is a widely prevalent skin disease that affects both children and adults. The aim of the study was to assess the association of perceived stress (single-item, self-reported) with AD (self-reported) in a sample of Korean adults using a cross-sectional research design. A cross-sectional study was conducted using data from 33,018 adults aged 20 years and older collected in the 2007-2012 Korea National Health and Nutrition Examination Surveys (KNHANES). An increased level of self-reported stress was positively associated with an increased prevalence of AD in Korean adults (p for trend <0.001). After adjusting for covariates, the odds ratios (ORs) of AD among participants reporting high and very high levels of stress were 1.81 (95% confidence interval (CI): 1.22, 2.67) and 2.17 (95% CI: 1.38, 3.42), respectively, compared with those who reported low levels of stress. This study found a statistically significant association between perceived stress and AD among Korean adults.

The relationship between suicidal behaviors and atopic dermatitis in Korean adolescents

Atopic dermatitis is a common skin disease in adolescents, which may have a negative effect on the mental and emotional health. We investigated the relationship between atopic dermatitis and suicidal behaviors in Korean adolescents. Participants included 74,186 adolescents (38,221 boys and 35,965 girls) in middle and high school who completed the Eighth Korea Youth Risk Behavior Web-Based Survey. There were significant associations between atopic dermatitis and suicidal behaviors for girls. The overestimation of weight perception might have an additive impact on suicidal risk among girls. However, there were no significant associations between atopic dermatitis and suicidal behaviors in boys.

DOCK8: regulator of Treg in response to corticotropin-releasing hormone

BACKGROUND

Atopic dermatitis (AD) is exacerbated by psychological factors, such as stress. We previously reported that corticotrophin-releasing hormone (CRH) treatment in AD patients decreased the proportion of IL-10(+) Tr1 cells, a subset of inducible regulatory T cells (Tregs). However, changes in the function of Tregs in response to CRH have yet to be studied.

METHODS

We analyzed the total proteins taken from CRH-treated and untreated Tregs from AD mice model (NC/Nga mice) using a quantitative proteomic analysis for the different protein expressions.

RESULTS

We found a statistically decreased protein level of DOCK8 in CRH-treated Tregs from AD mice. In human, DOCK8 protein levels were also significantly decreased in CRH-treated Tregs from AD patients. Moreover, the expression of DOCK8 in Tregs was inversely correlated with the anxiety levels in the AD patients. In addition to the clinical correlation of DOCK8 with the stress level of AD patients, the knockdown of DOCK8 in Tregs reduced the inhibitory cytokines, IL-10 and TGF-β, and inhibited the regulatory function of Tregs to suppress the proliferation and TNF-α release of CD4(+) T cells in vitro.

CONCLUSION

This study provides new insights on the mechanisms of stress-induced AD aggravation by showing that CRH downregulated DOCK8 expression in Tregs that not only clinically correlates with anxiety levels of AD patients but also regulates suppressive function of Tregs on CD4(+) T cells.

Consensus Guidelines for the Treatment of Atopic Dermatitis in Korea (Part I): General Management and Topical Treatment

Background

Since the treatment guidelines for atopic dermatitis (AD) were released by the Korean Atopic Dermatitis Association (KADA) work group in 2006, there have been several advances in AD management.

Objective

We aimed to establish updated evidence- and experience-based treatment guidelines for Korean AD.

Methods

We collected a database of references from relevant systematic AD reviews and guidelines regarding general AD management such as bathing and skin care, avoidance of exacerbating factors, education and psychosocial support, and the use of moisturizers and topical anti-inflammatory and antipruritic drugs. Evidence for each statement was graded and the strength of the recommendation for each statement classified. Thirty-nine KADA council members participated in three rounds of voting to establish an expert consensus of recommendations.

Results

Basic AD treatment includes proper bathing and skin care, avoidance of exacerbating factors, proper education and psychosocial support, and use of moisturizers. The regular use of moisturizer has a steroid-sparing effect and reduces relapse episodes. The short- and long-term use of topical corticosteroids and calcineurin inhibitors improves AD symptoms and should be encouraged to use in an active and proactive treatment. Wet-wrap therapy can be used for rapid recovery of acute exacerbation. Topical antipruritic drugs cannot be recommended for the treatment of AD.

Conclusion

This report provides up-to-date evidence- and experience-based treatment guidelines for AD regarding general management and topical treatment. In addition, the average agreement scores obtained by a panel of experts based on the Korean healthcare system and patient adherence are presented.

Stress sensitivity in patients with atopic dermatitis in relation to the translocator protein 18 kDa (TSPO)

Atopic dermatitis (AD) is a chronic inflammatory skin disease, characterized by pruritic and eczematous skin lesions and dermatitis that worsens under stressful conditions. However, the relation of these symptoms to an individual's stress sensitivity is not well understood. On the other hand, expression of the translocator protein (18 kDa) (TSPO), formerly known as the peripheral-type benzodiazepine receptor, has been used as a biological marker of trait anxiety and stress sensitivity. The present study was designed to address this issue by examining TSPO in patients with AD. Fifty-two patients with AD (30 male and 22 female) and 163 healthy volunteers (89 male and 74 female) participated in this study. State-Trait Anxiety Inventory (STAI) scores were significantly higher in patients with AD, especially male patients, than in healthy subjects. The expression of platelet TSPO, as determined with a binding assay with [(3)H] PK11195, was also significantly higher in patients with AD, indicating that AD is a stress-responsive disease. In genomic analysis using lymphocytes, a single-nucleotide polymorphism of the human TSPO gene at exon 4 (485G>A), which is presumably associated with an individual's stress sensitivity, showed significantly lower frequencies of G/G and higher frequencies of G/A in patients with AD than in healthy subjects. The severity of AD, as determined with the Scoring of Atopic Dermatitis index, was correlated with TSPO expression in male patients with the G/A phenotype. In conclusion, the present study provides new evidence that variation in the TSPO gene affects susceptibility to AD.

Gender differences in depression and anxiety among atopic dermatitis patients

Background:

Dermatological patients invariably suffer one or the other psychological problems which may escalate to the extent of a mental disorder. One of the most common dermatological disorders is atopic dermatitis (AD), but the literature has limited data on gender differences for psychiatric morbidity in such patients.

Aims:

To evaluate and compare gender differences in the prevalence of depression and anxiety in AD.

Materials and Methods:

This cross-sectional study with consecutive sampling was done in an outpatient clinic of Dermatology at a Tertiary Care Center. AD subjects giving informed consent were evaluated on a brief semi-structured performa for collecting demographic and clinical information. Primary Care Evaluation of Mental Disorders (PRIME-MD) was used to assess the presence of psychiatric symptoms in these patients. Descriptive analysis was done for the socio-demographic profile and independent sample t-test, Chi-square and Cramer's V test was carried out to find in-between group differences for males and females.

Results:

A total of 81 patients were included in the final analysis (males = 36, females = 45) with no significant difference in mean age between male and female subjects (36.14 ± 17.62 and 33.98 ± 14.49 years, respectively; P = 0.54). When including moderate to severe grade of depression or anxiety, the current study found prevalence rates of 15% and 12% respectively. Females had significantly more anxiety and depression scores than males (P = 0.04 and P = 0.03 respectively).

Conclusions:

There is a female preponderance of depression and anxiety disorder in AD patients.

5-HT1A/1B receptors as targets for optimizing pigmentary responses in C57BL/6 mouse skin to stress

Stress has been reported to induce alterations of skin pigmentary response. Acute stress is associated with increased turnover of serotonin (5-hydroxytryptamine; 5-HT) whereas chronic stress causes a decrease. 5-HT receptors have been detected in pigment cells, indicating their role in skin pigmentation. To ascertain the precise role of 5-HT in stress-induced pigmentary responses, C57BL/6 mice were subjected to chronic restraint stress and chronic unpredictable mild stress (CRS and CUMS, two models of chronic stress) for 21 days, finally resulting in abnormal pigmentary responses. Subsequently, stressed mice were characterized by the absence of a black pigment in dorsal coat. The down-regulation of tyrosinase (TYR) and tyrosinase-related proteins (TRP1 and TRP2) expression in stressed skin was accompanied by reduced levels of 5-HT and decreased expression of 5-HT receptor (5-HTR) system. In both murine B16F10 melanoma cells and normal human melanocytes (NHMCs), 5-HT had a stimulatory effect on melanin production, dendricity and migration. When treated with 5-HT in cultured hair follicles (HFs), the increased expression of melanogenesis-related genes and the activation of 5-HT1A, 1B and 7 receptors also occurred. The serum obtained from stressed mice showed significantly decreased tyrosinase activity in NHMCs compared to that from nonstressed mice. The decrease in tyrosinase activity was further augmented in the presence of 5-HTR1A, 1B and 7 antagonists, WAY100635, SB216641 and SB269970. In vivo, stressed mice received 5-HT precursor 5-hydroxy-l-tryptophan (5-HTP), a member of the class of selective serotonin reuptake inhibitors (fluoxetine; FX) and 5-HTR1A/1B agonists (8-OH-DPAT/CP94253), finally contributing to the normalization of pigmentary responses. Taken together, these data strongly suggest that the serotoninergic system plays an important role in the regulation of stress-induced depigmentation, which can be mediated by 5-HT1A/1B receptors. 5-HT and 5-HTR1A/1B may constitute novel targets for therapy of skin hypopigmentation disorders, especially those worsened with stress.

Chronic psychological stress suppresses contact hypersensitivity: potential roles of dysregulated cell trafficking and decreased IFN-γ production

Increasing evidence shows that psychological stress can have dramatic impacts on the immune system, particularly the cutaneous immune response in dermatological disorders. While there have been many studies examining the impact of acute psychological stress on contact hypersensitivity there are relatively few studies concerning the impact of chronic psychological stress. Furthermore, the local immunological mechanisms by which chronic psychological stress impacts contact hypersensitivity still remain to be explored. Here we show that restraint-induced chronic psychological stress stimulates activation of the hypothalamus-pituitary-adrenal axis and delays weight gain in female BALB/c mice. We observed that chronic psychological stress reduces the cutaneous immune response as evidence by reduced ear swelling. This correlated with a significant decrease in the inflammatory cell infiltrate. On the other hand, chronic psychological stress does not influence T cell proliferation, activation, or sensitivity to corticosterone but does increase CD4(+) and CD8(+) T cell percentages in draining lymph nodes during a contact hypersensitivity reaction. Chronic psychological stress induces a decrease in overall circulating white blood cells, lymphocytes, and monocytes during a contact hypersensitivity reaction suggesting extravasation from the circulation. Finally, we found markedly reduced local IFN-γ production in chronically stressed animals. Based on these findings we propose that chronic psychological stress reduces contact hypersensitivity due to dysregulated cell trafficking and reduced production of IFN-γ.

Psychological stress with long-standing allergic dermatitis causes psychodermatological conditions in mice

Psychological factors have long been assumed to be involved in the pathogenesis of allergic skin diseases. The effects of psychological stress on allergic contact dermatitis (ACD) have been experimentally well investigated; however, the effects of ACD on stress responses are largely unknown. Here, we report that preceding chronic ACD dramatically affects the behavioral and physiological stress responses to social isolation (a psychological stressor). In male BALB/c mice, social isolation combined with long-standing (>2 months) ACD by repeated hapten application caused characteristic symptoms, including chronic dermatitis from persistent self-scratching, behavioral changes related to fear/anxiety, and elevated serum IgE levels. The symptoms were maintained by social isolation alone without further hapten application after the onset, and were improved by resocialization. Treatment with topical corticosteroids exacerbated chronic scratch dermatitis, whereas it was effective for chronic ACD. These results show that the symptoms represent a de novo development of a specific disease state and not a mere exacerbation of a preexisting allergic inflammation. With this experimental protocol, similar results were obtained in several other strains of mice. This murine model provides a tool for investigating the pathogenesis and treatment of allergic skin disease with psychodermatological aspects.

Allergic disease is associated with epilepsy in childhood: a US population-based study

BACKGROUND

Previous studies using animal models suggest an association between allergic disease and epilepsy. We sought to determine whether allergic disease is associated with epilepsy in children.

METHODS

We used the 2007-2008 National Survey of Children's Health, a US population-based study of 91 642 children aged 0-17 years to determine the association between the prevalence of epilepsy and allergic disease, including asthma, atopic dermatitis (AD)/eczema, hay fever, and food allergies. Multivariate logistic regression models were constructed that controlled for confounding variables.

RESULTS

The US lifetime prevalence of childhood epilepsy was 1.03% and was significantly associated with older age, male sex, lower household income, family structure and history of brain injury or concussion. Children with ≥1 allergic disease had more epilepsy in their lifetime than nonallergic children (logistic regression, adjusted odds ratio [95% confidence interval] = 1.79 [1.37-2.33]). Lifetime prevalence (2.30 [1.50-3.52]) and one-year prevalence of asthma (2.00 [1.41-2.84]), AD/eczema (1.73 [1.17-2.56]), hay fever (1.93 [1.41-2.65]) and food allergies (2.69 [1.38-4.01]) were associated with increased odds of ever being diagnosed with epilepsy. Similar results were found for current history of epilepsy. Severe AD/eczema (3.89 [1.34-11.32]) [corrected] and hay fever (2.46 [1.11-5.41]) were associated with even higher odds of epilepsy compared with mild/moderate disease. As the number of allergic diseases increased, so did the odds of lifetime history and current history of epilepsy.

CONCLUSIONS

The US prevalence of epilepsy is associated with allergic diseases in children. Further studies are needed to determine whether allergic inflammation contributes toward epileptogenesis.

Comparison of the psychological impacts of asymptomatic and symptomatic cutaneous diseases: vitiligo and atopic dermatitis

Background

Vitiligo and atopic dermatitis (AD) are common dermatological disorders which may cause significant psychological and social distress leading to impaired quality of life (QoL) in patients.

Objective

We evaluated the degree of psychological stress and impairment of QoL in vitiligo patients as compared with AD patients and normal controls (NCs).

Methods

A total of 60 patients from each group and 60 NCs were enrolled. Five questionnaires on depression (Beck depression inventory, BDI), state anxiety (SA) and trait anxiety (TA), interaction anxiousness (IAS), private body consciousness (PBC) and dermatologic QoL were used.

Results

The vitiligo patients had a significantly higher level of TA (p<0.01), PBC (p<0.001) and impaired QoL (p<0.001) than NCs, but not BDI, SA and IAS. The AD patients had significantly higher scores for all five questionnaire items compared with NCs. In the comparison between the AD and vitiligo groups, all of the indexes except body consciousness were higher in AD patients than in vitiligo patients: BDI (p<0.01), SA (p<0.05), TA (p<0.001), IAS (p<0.01) and impaired QoL (p<0.001). Exposure of vitiligo lesions was not a significant variable in the analysis of the contribution of clinical variables of vitiligo on psychological stress and QoL.

Conclusion

Vitiligo, which is not accompanied by any symptoms, involves less psychological impact than AD, which is accompanied by itching. Compared to NCs, however, the elevated general anxiety and body consciousness in patients with vitiligo suggests that they may be more concerned with the aggravation of hypopigmented patches than difficulties in social interactions.

Chronic pruritus associated with dermatologic disease in infancy and childhood: update from an interdisciplinary group of dermatologists and pediatricians

An effective treatment strategy for chronic pruritus in children with dermatologic disorders should consider the multidimensional aspects of pruritus, the unique challenges associated with treating pruritic skin disorders in the pediatric population, and evidence-based therapies with demonstrated antipruritic benefits and clinically relevant effects on patient/family quality of life (QoL). The Course of Advanced Learning for the Management of ITch (CALM-IT) Task Force is an interdisciplinary group of experts specializing in core aspects of pruritus treatment, integrating pediatrics, dermatology, psychotherapy, pruritus management, and sleep. CALM-IT recently convened to provide updated guidance on managing chronic pruritus associated with dermatologic diseases in pediatric patients, with a special focus on atopic dermatitis (AD) and chronic spontaneous urticaria (csU). This review highlights the updated concepts and best practices, which were built upon international PRACTALL consensus and modified for children and infants with AD and csU. CALM-IT supports the routine use of basic skin therapy and the escalation of topical medications, according to severity and focused on rapid itch control. Anti-inflammatory agents should be appropriate for infants and children (i.e., with an optimized therapeutic index) and have proven antipruritic properties, such as those demonstrated by methylprednisolone aceponate. New experimental findings do not support the use of non-sedating oral antihistamines as adjuvant antipruritic therapy for AD. In csU, oral H1 -antihistamine use is justified, consistent with the distinct pathophysiologic mechanisms of itch underlying AD and csU. All encompassing QoL assessments should consider the burden of both patient and caregiver and should address outstanding unmet clinical needs of pediatric patients. Future research areas include integrated QoL assessments and multidisciplinary treatment programs with pediatric-targeted pruritic therapies providing rapid itch control.

Does stress increase the risk of atopic dermatitis in adolescents? results of the Korea Youth Risk Behavior Web-based Survey (KYRBWS-VI)

This study investigated the relationship between level of stress in middle and high school students aged 12–18 and risk of atopic dermatitis. Data from the Sixth Korea Youth Risk Behavior Web-based Survey (KYRBWS-VI), a cross-sectional study among 74,980 students in 800 middle schools and high schools with a response rate of 97.7%, were analyzed. Ordinal logistic regression analyses were conducted to determine the relationship between stress and atopic dermatitis with severity. A total of 5,550 boys and 6,964 girls reported having been diagnosed with atopic dermatitis. Younger students were more likely to have atopic dermatitis. Interestingly, the educational level of parents was found to be associated with having atopic dermatitis and having more severe condition. In particular, girls with mothers with at least college education had a 41% higher risk of having atopic dermatitis and severe atopic condition (odds ratio (OR)) = 1.41, 95% CI, 1.22–1.63; P<0.0001) compared with those with mothers who had attended middle school at most. Similar trend was shown among both boys and girls for their father's education level. The stress level was found to be significantly associated with the risk of atopic dermatitis. Compared to boys with who reported “no stress”, boys with “very high” stress had 46% higher the risk of having more severe atopic dermatitis (OR = 1.46, 95% CI, 1.20–1.78; P<0.0001), 44% higher (OR = 1.44, 95% CI, 1.19–1.73; P<0.0001) with “high” stress, and 21% higher (OR = 1.21, 95% CI, 1.00–1.45; P = 0.05) with “moderate” stress. In contrast, we found no statistically significant relationship between stress and atopic dermatitis in girls. This study suggests that stress and parents' education level were associated with atopic dermatitis. Specifically, degree of stress is positively correlated with likelihood of being diagnosed with this condition and increasing the severity.

Psychological distress in asthma and allergy: the Västerbotten Environmental Health Study

With the aim to better understand the association between asthma/allergy and psychological distress, it was hypothesized that levels of stress, exhaustion, anxiety, depression, and health worries for environmental pollution would be higher in allergic asthma, allergic rhinitis, and atopic dermatitis than in non-allergic asthma and in referents without asthma or allergy. Taking part in the population-based Västerbotten Environmental Health Study (aged 18-79 years), 76 respondents reported a physician-based diagnosis of allergic asthma, 86 reported non-allergic asthma, 190 reported allergic rhinitis, and 46 reported atopic dermatitis as the only form of asthma/allergy. A group of 2876 respondents without an asthma/allergy diagnosis constituted as referents. The participants responded to the Perceived Stress Scale, the Shirom-Melamed Burnout Questionnaire, the Hospital Anxiety and Depression Scale, and the Environmental Pollution subscale of the Modern Health Worries Scale. Levels of stress, exhaustion, and anxiety were higher in allergic asthma and atopic dermatitis than in non-allergic asthma, allergic rhinitis, and among referents, and there was a strong tendency of such group differences for depression and health worries. The results imply that stress reduction and treatment of negative affect may in certain cases be fruitful interventions in patients with atopy.

Mental health comorbidity in patients with atopic dermatitis

BACKGROUND

Recent data, primarily from Europe, suggest that children with atopic dermatitis (AD) might be at increased risk of mental health disorders.

OBJECTIVE

We aimed to quantify the mental health burden associated with pediatric AD in the United States.

METHODS

A cross-sectional study design was used analyzing data from the 2007 National Survey of Children's Health, a survey reporting on the health status of 92,642 noninstitutionalized children aged 0 to 17 years. The lifetime prevalence of various provider-diagnosed mental health conditions was calculated for those with and without a history of AD.

RESULTS

The odds of having attention deficit hyperactivity disorder was significantly increased in children with AD compared with the odds in control subjects without AD (odds ratio, 1.87; 95% CI, 1.54-2.27), even after controlling for known confounders. The adjusted odds ratios for depression, anxiety, conduct disorder, and autism were 1.81 (95% CI, 1.33-2.46), 1.77 (95% CI, 1.36-2.29), 1.87 (95% CI, 1.46-2.39), and 3.04 (95% CI, 2.13-4.34), respectively, and these estimates were all statistically significant. A clear dose-dependent relationship was observed between the prevalence of a mental health disorder and the reported severity of the skin disease.

CONCLUSIONS

Our data reveal a striking association between mental health disorders and AD in the US pediatric population. The severity of the skin disease alters the strength of the association. Prospective cohort studies are needed to verify these associations and to explore underlying mechanisms. Strategies to prevent AD or to aggressively treat early skin inflammation might modify the risk of mental health disorders in at-risk children.

Psychological Stress and the Cutaneous Immune Response: Roles of the HPA Axis and the Sympathetic Nervous System in Atopic Dermatitis and Psoriasis

Psychological stress, an evolutionary adaptation to the fight-or-flight response, triggers a number of physiological responses that can be deleterious under some circumstances. Stress signals activate the hypothalamus-pituitary-adrenal (HPA) axis and the sympathetic nervous system. Elements derived from those systems (e.g., cortisol, catecholamines and neuropeptides) can impact the immune system and possible disease states. Skin provides a first line of defense against many environmental insults. A number of investigations have indicated that the skin is especially sensitive to psychological stress, and experimental evidence shows that the cutaneous innate and adaptive immune systems are affected by stressors. For example, psychological stress has been shown to reduce recovery time of the stratum corneum barrier after its removal (innate immunity) and alters antigen presentation by epidermal Langerhans cells (adaptive immunity). Moreover, psychological stress may trigger or exacerbate immune mediated dermatological disorders. Understanding how the activity of the psyche-nervous -immune system axis impinges on skin diseases may facilitate coordinated treatment strategies between dermatologists and psychiatrists. Herein, we will review the roles of the HPA axis and the sympathetic nervous system on the cutaneous immune response. We will selectively highlight how the interplay between psychological stress and the immune system affects atopic dermatitis and psoriasis.

Comorbidity in Atopic Dermatitis

The negative impact of atopic dermatitis (AD) often extends beyond the skin. Children with AD experience increased rates of infectious, mental health, and allergic diseases compared to their non-atopic peers. The mechanisms underlying these associations remain elusive. New insights from genetic and epidermal research pinpoint the skin barrier as a primary initiator of AD. Epicutaneous sensitization represents an intriguing new model which links a disrupted skin barrier to the later development of IgE-mediated diseases in patients with AD. Recent epidemiological studies have identified new comorbidities linked to AD as well, including several mental health disorders and obesity. This manuscript reviews the recent literature regarding both classic and newly described AD comorbidities.

[Roles of histamine in the exacerbated allergic dermatitis]

We established a novel dermatitis model in mice earlobes and analyzed the roles of histamine using specific antagonists for histamine receptors. After sensitization with picryl chloride (PiCl) by painting it on the earlobes of cyclophosphamide-treated mice, 12-O-tetradecanoylphorbol 13-acetate (TPA) was painted twice at the same site, and then allergic inflammation was induced by painting with PiCl. Histamine antagonists and cyclosporin A were administered i.v. The application of TPA shifted the PiCl-induced allergic inflammation from a delayed-type response to a biphasic response and increased the infiltration of eosinophils and mast cells at the inflammatory site. In this model, the PiCl-induced increase in the thickness of the earlobe in the immediate phase was suppressed by the histamine H₁ antagonist pyrilamine. In contrast, the increase in the swelling in the late phase and the infiltration of eosinophils were suppressed by the H₃/H₄ antagonist thioperamide. The inhibitory effect of the combined treatment with pyrilamine and thioperamide on TPA-modified contact dermatitis was as potent as that of cyclosporin A. Histamine plays significant roles in early-phase swelling via H₁ receptors and in late-phase swelling via H₃/H₄ receptors in this TPA-modified allergic dermatitis model.

Neural pathways in allergic inflammation

Allergy is on the rise worldwide. Asthma, food allergy, dermatitis, and systemic anaphylaxis are amongst the most common allergic diseases. The association between allergy and altered behavior patterns has long been recognized. The molecular and cellular pathways in the bidirectional interactions of nervous and immune systems are now starting to be elucidated. In this paper, we outline the consequences of allergic diseases, especially food allergy and asthma, on behavior and neural activity and on the neural modulation of allergic responses.

Somatization: the under-recognized factor in nonspecific eczema. The Hordaland Health Study (HUSK)

BACKGROUND

Psychodermatology has focused primarily on depression and anxiety in eczema. Skin symptoms are listed among many others for the ICD-10 diagnosis of somatization disorder. Somatization (unexplained somatic symptoms) is highly prevalent in the general population, but its association with eczema is yet to be empirically investigated.

OBJECTIVES

We therefore explored the association between somatization and eczema by examining the extent of somatization in eczema compared with allergic rhinitis, and by examining if eczema was more strongly associated with somatization than with anxiety and depression. Finally, we aimed to examine the relationship between the site of eczema and somatization for individual somatic symptoms and for somatic symptoms as a whole.

METHODS

For this population-based cross-sectional study we employed data from the Hordaland Health Study (HUSK) with 15,225 participants aged 41-48 years. Information on nonspecific eczema, allergic rhinitis, somatization, anxiety, depression and other covariates was obtained by self-report.

RESULTS

The association between nonspecific eczema and somatization was strong and followed a dose-response pattern, as did all somatic symptoms in our index of somatization when analysed separately. The association between nonspecific eczema and somatization was stronger than that between rhinitis and somatization, and also the association between nonspecific eczema and anxiety and depression. In multivariate models, somatization accounted for most of the association between nonspecific eczema and anxiety/depression. In contrast, the association between nonspecific eczema and somatization was robust for adjustment for anxiety/depression.

CONCLUSIONS

Somatization was strongly associated with nonspecific eczema. This applies to a whole range of somatic symptoms constituting the construct of somatization. There is hardly any mention of somatization in leading dermatological journals, in contrast to anxiety and depression which are frequently reported in eczema. We speculate that this under-recognition of somatization in the dermatological literature may correspond to under-recognition of this factor also in clinical practice.

Factors accounting for the association between anxiety and depression, and eczema: the Hordaland health study (HUSK)

Background

The association between anxiety and depression, and eczema is well known in the literature, but factors underlying this association remain unclear. Low levels of omega-3 fatty acids and female gender have been found to be associated with both depression and eczema. Somatization and health anxiety are known to be associated with anxiety and depression, further, somatization symptoms and health anxiety have also been found in several dermatological conditions. Accordingly, omega-3 fatty acid supplement, female gender, somatization and health anxiety are possible contributing factors in the association between anxiety and depression, and eczema. The aim of the study is to examine the relevance of proposed contributing factors for the association between anxiety and depression, and eczema, including, omega-3 fatty acid supplement, female gender, health anxiety and somatization.

Methods

Anxiety and depression was measured in the general population (n = 15715) employing the Hospital Anxiety and Depression Scale (HADS). Information on eczema, female gender, omega-3 fatty acid supplement, health anxiety and somatization was obtained by self-report.

Results

Somatization and health anxiety accounted for more than half of the association between anxiety/depression, and eczema, while the other factors examined were of minor relevance for the association of interest.

Conclusions

We found no support for female gender and omega-3 fatty acid supplement as contributing factors in the association between anxiety/depression, and eczema. Somatization and health anxiety accounted for about half of the association between anxiety/depression, and eczema, somatization contributed most. The association between anxiety/depression, and eczema was insignificant after adjustment for somatization and health anxiety. Biological mechanisms underlying the mediating effect of somatization are yet to be revealed.

Children with Atopic Dermatitis Do Not Have More Anxiety or Different Cortisol Levels Compared with Normal Children

Background:

The hypothalamic-pituitary-adrenal axis has an important immunoregulatory role under stress, and stressmediated anxiety has been reported to be associated with alterations in immune functions and attenuated cortisol levels in atopic dermatitis (AD) patients.

Objective:

We investigated serum basal cortisol and anxiety levels in pediatric AD patients and compared them with those of controls.

Methods:

Basal serum cortisol levels were measured in 36 pediatric AD patients (aged 9–16 years) and 36 control subjects (aged 9–15 years). Anxiety was assessed by the trait anxiety subscale (TAI-C) of the State-Trait Anxiety Inventory for Children. The severity of AD was assessed by the objective severity scoring of AD (SCORing Atopic Dermatitis [SCORAD]).

Results:

Data analysis showed no statistical difference for the basal serum cortisol levels ( p = .383) and the TAI-C ( p = .730) between the two groups. No significant correlation was found between the basal cortisol values and the TAI-C scores in the AD group ( p = .290). The SCORAD index was correlated with the TAI-C scores ( p < .05) but not correlated with the basal serum cortisol values in AD patients ( p = .06).

Conclusion:

Children with AD do not have more anxiety or different cortisol levels when compared with normal children, but the severe symptomatology of AD itself may cause anxiety levels to increase in children with AD.

Inhibitory effects of antipsychotic and anxiolytic agents on stress-induced degranulation of mouse dermal mast cells

BACKGROUND

Various psychological stresses induce degranulation of mast cells. It has been confirmed by animal experiments that stress induced by restraint promotes mast-cell degranulation in various organs, and that the degranulation is inhibited by pretreatment with corticotropin-releasing factor (CRF)-neutralizing antibodies, CRF receptor antagonists, and neurotensin (NT) antagonists. Previous studies have suggested that anxiety and fear induced in animals by psychological stressors promote the production and release of various neuropeptides and neurotransmitters, and induce degranulation of mast cells in several organs.

AIM

To evaluate the effect of prior treatment with antipsychotic and anxiolytic agents to inhibit foot-shock (FS) stress-induced degranulation of mouse dermal mast cells.

METHODS

Using a communication box system, FS was administered to mice and the degranulated dermal mast cells were counted. Chlorpromazine (2 or 4 mg/kg body weight), tandospirone (10 mg/kg body weight) or CRA1000, a selective non-peptidic CRF receptor type 1 antagonist (10 or 100 mg/kg body weight) was injected intraperitoneally 1 h before exposure to FS.

RESULTS

After FS was administered, the number of dermal mast cells did not change. However, FS significantly increased the proportion of degranulated mast cells. Pretreatment of mice with chlorpromazine hydrochloride, an antipsychotic agent (2 or 4 mg/kg), or the anxiolytic agents tandospirone citrate (10 mg/kg) or CRA1000 (10 or 100 mg/kg), significantly inhibited the FS-induced mast-cell degranulation (P < 0.05, P < 0.01, P < 0.05, P < 0.05, and P < 0.05, respectively).

CONCLUSIONS

Antipsychotic and anxiolytic agents may be effective treatments for stress-aggravated inflammatory skin diseases by inhibition of mast-cell degranulation.

[Suicidal ideation, anxiety and depression in adult patients with atopic dermatitis]

BACKGROUND

Atopic dermatitis is a chronic skin disease which is increasing in incidence and prevalence. An understanding of the mental burden patients carry is essential for successful psychodermatological treatment.

PATIENTS AND METHODS

62 adult atopic dermatitis patients were tested with a questionnaire and compared with a matched group of 62 healthy persons. Using the questionnaire for assessing suicide risk of Pöldinger, suicidal ideations were assessed. Anxiety and depression were detected by using HADS-D; the severity of symptoms by patients' self-evaluation based on SCORAD index. Finally, the onset of atopic dermatitis was established.

RESULTS

A significantly higher level of suicidal ideation, anxiety and depression was shown among patients with atopic dermatitis. All three aspects showed a medium effect size. Strong correlations between severity of symptoms and psychological burden were observed. 16.1% of patients with atopic dermatitis suffered from suicidal ideation, while only 1.6% in control group did, producing an odds ratio of 11.73 (95%CI 1.45-94.71).

CONCLUSION

Suicidal ideation, anxiety and depression are important factors, which should be addressed when treating atopic dermatitis.

Evidence for a regulatory role of alpha 4-integrins in the maturation of eosinophils generated from the bone marrow in the presence of dexamethasone

BACKGROUND

Although eosinophils co-express multiple integrin receptors, the contributions of integrins to eosinophil development have not been explored. We previously described extensive aggregation and cytological immaturity in eosinophils developing in bone-marrow (BM) cultures exposed to dexamethasone. Here we examined the relationship of alpha 4 integrins with these effects of dexamethasone.

OBJECTIVES

We evaluated: (a) the effects of exposure to dexamethasone in BM culture on eosinophil expression of alpha 4 integrin receptors and ligands; (b) the contribution of alpha 4 integrins to eosinophil aggregation and maturation.

METHODS

Cultures were established with IL-5 (alone or with dexamethasone) for up to 7 days, and eosinophil production, alpha 4 integrin receptor/ligand expression, aggregation and morphology were evaluated before and after targeting alpha 4 integrin-dependent adhesions. Because prostaglandin E2 (PGE2) modifies the effects of dexamethasone on eosinophilopoiesis, PGE2 effects on alpha 4 integrin expression and function were also evaluated.

RESULTS

Dexamethasone increased the yield of eosinophils up to day 7. The frequency of eosinophils expressing alpha 4, beta1 and beta 7 integrin receptors at day 7 was also increased by dexamethasone. Eosinophils also expressed the alpha 4 beta 1 ligand, VCAM-1. Dexamethasone increased the expression of alpha 4 integrin and VCAM-1 in aggregates containing eosinophils as early as day 3. PGE2, added up to day 3, modified the effects of dexamethasone to suppress the expression of alpha 4 integrin, decrease aggregation and promote cytological maturation of eosinophils recovered at day 7. Dissociation of immature eosinophils from clusters present at day 3 by reagents targeting alpha 4 or beta1 integrins or VCAM-1 also induced cytological maturation. The concordant effects of targeting alpha 4 integrins with drugs and antibodies support a relationship between alpha 4-mediated aggregation and maturational arrest.

CONCLUSIONS

These observations support a novel role for alpha 4 integrin receptors and ligands in eosinophilopoiesis. In addition, increased alpha 4 expression following glucocorticoid exposure may contribute to the retention and accumulation of eosinophils in haemopoietic tissue.

Could Anxiety, Hopelessness and Health Locus of Control Contribute to the Outcome of a Kidney Transplant?

My main objective in this study was to determine whether psychological factors contribute to the rejection, or acceptance, of a transplanted kidney. It was hypothesised that psychological factors such as state and trait anxiety, hopelessness and locus of control would affect immune responses, and therefore contribute to the acceptance or rejection of a transplanted kidney. The research design used was an ex-post facto, comparative design. An initial sample of 85 patients, on the waiting list for a renal transplant, completed the questionnaires voluntarily. The data obtained from these questionnaires was stored until a sufficient number of these patients had undergone a transplant (23 patients in total). Based on the outcome (six months post-operatively) of the transplant, patients were categorised in either the Reject or Accept group. A period of six months post-operatively was decided on in order to allow for the possibility of hyperacute and acute rejection. In the final analysis there were 11 patients in the Accept group, and 12 patients in the Reject group. In order to test the hypotheses, patients were tested by means of the Spielberger State-Trait Anxiety Scale, Hopelessness Scale, and the Health Locus of Control Scale. The analysis of the data indicated a significant difference in the mean score for the two groups with relation to state anxiety, trait anxiety and health locus of control. The group that accepted the transplanted kidney had a more internal health locus of control and higher state and trait anxiety scores than the group that rejected the kidney.

The association between anxiety sensitivity and atopy in adult asthmatics

There is growing evidence linking psychological stress to atopic disease, particularly asthma. Anxiety sensitivity, which is the fear of anxiety-related symptoms, may be particularly important in the study of anxiety and atopic disease. The present study examined the association between atopy and anxiety sensitivity in adult asthmatics. A total of 217 asthma patients who had undergone standard pulmonary function and allergen skin prick testing were included. Participants completed the Anxiety Sensitivity Index, Penn State Worry Questionnaire, Type D Personality Scale-16 and Beck Depression Inventory-II on the day of their asthma clinic visit. Total Anxiety Sensitivity Index score was found to be significantly higher in atopic (M = 17.15, SE = .9) versus non-atopic (M = 12.68, SE = 1.5) asthmatics, independent of age, sex, smoking status, asthma severity, asthma duration, and anxiolytic medication use (F = 6.11, p = .014). There was no evidence for a significant association between any of the other questionnaire scores and atopic status.

The skin as a mirror of the soul: exploring the possible roles of serotonin

Serotonin (5-hydroxytryptamine; 5-HT) is an important mediator of bidirectional interactions between the neuroendocrine system and the skin. The rate of synthesis of 5-HT from l-tryptophan can be enhanced by brain-derived neuronal growth factor, cytokines, exposure to ultraviolet light and steroids. The major source of 5-HT in the skin are platelets, which, upon aggregation, release this biogenic amine. Moreover, the epidermal and dermal skin express the enzymes required for the transformation of tryptophan to 5-HT, and certain skin cells, such as melanocytes, have been demonstrated to produce 5-HT. In addition, rodent mast cells produce 5-HT, but human mast cells have not yet been fully examined in this respect. Skin cells express functionally active, membrane-bound receptors for 5-HT, as well as proteins that transport 5-HT. The interactions of 5-HT with these various proteins determines the nature, magnitude and duration of serotonergic responses. The immune and vasculature systems in the skin are traditional targets for bioregulation by 5-HT. Moreover, recent findings indicate that keratinocytes, melanocytes and dermal fibroblasts also respond to this amine in various ways. Thus, mammalian skin is both a site for the production of and a target for bioregulation by 5-HT. This indicates that agonists and antagonists directed towards specific 5-HT receptors could be useful in connection with treatment of skin diseases. Based on our increasing knowledge concerning these receptors and their plasticity, future research will focus on the development of serotonergic drugs that exert metabotrophic effects on the cells of the skin without affecting the central nervous system.